Plantar Fasciitis

Topic Overview

What is plantar fasciitis?

Plantar fasciitis (say "PLAN-ter fash-ee-EYE-tus") is the most common
cause of heel pain. The
plantar fascia is the flat band of tissue (ligament) that
connects your heel bone to your toes. It supports the arch of your foot. If you
strain your plantar fascia, it gets weak, swollen, and irritated (inflamed). Then your heel or the bottom of your foot
hurts when you stand or walk.

Plantar fasciitis is common in
middle-aged people. It also occurs in younger people who are on their feet a
lot, like athletes or soldiers. It can happen in one foot or both feet.

What causes plantar fasciitis?

Plantar fasciitis
is caused by straining the ligament that supports your arch. Repeated strain
can cause tiny tears in the ligament. These can lead to pain and swelling. This
is more likely to happen if:

What are the symptoms?

Most people with plantar
fasciitis have pain when they take their first steps after they get out of bed
or sit for a long time. You may have less stiffness and pain after you take a
few steps. But your foot may hurt more as the day goes on. It may hurt the most
when you climb stairs or after you stand for a long time.

How is plantar fasciitis diagnosed?

Your doctor
will check your feet and watch you stand and walk. He or she will also ask
questions about:

Your past health, including what illnesses or
injuries you have had.

Your symptoms, such as where the pain is and
what time of day your foot hurts most.

How active you are and
what types of physical activity you do.

Your doctor may take an X-ray of your foot if he or she
suspects a problem with the bones of your foot, such as a
stress fracture.

How is it treated?

No single treatment works best
for everyone with plantar fasciitis. But there are many things you can try to
help your foot get better:

Give your feet a rest. Cut back on activities
that make your foot hurt. Try not to walk or run on hard surfaces.

To reduce pain and swelling, try putting ice on your heel. Or take
an over-the-counter pain reliever like ibuprofen (such as Advil or Motrin) or naproxen (such as Aleve).

Do
toe stretches, calf stretches and
towel stretches several times a day, especially when you first get up in the
morning. (For towel stretches, you pull on both ends of a rolled towel that you place under the ball of your foot.)

Get a new pair of shoes. Pick shoes with good arch
support and a cushioned sole. Or try heel cups or shoe inserts (orthotics). Use them in both shoes, even if only one
foot hurts.

If these treatments do not help, your doctor may recommend
splints that you wear at night, shots of
medicine (such as a steroid) in your heel, or other treatments.
You probably will not need surgery. Doctors only suggest it for people who
still have pain after trying other treatments for 6 to 12 months.

How long will it take for the pain to go away?

Plantar fasciitis most often occurs because of injuries that have
happened over time. With treatment, you will have less pain within a few weeks.
But it may take time for the pain to go away completely. It may take a few months to a
year.

Stay with your treatment. If you don't, you may have
constant pain when you stand or walk. The sooner you start treatment, the
sooner your feet will stop hurting.

Cause

Exactly what causes
plantar fasciitis is not well understood. But it
probably develops as the result of repeated small tears in the
plantar fascia. Normally when you walk, your plantar fascia stretches as your
foot strikes the ground. If the plantar fascia is strained by the way you walk
or by repeated stress, it can become weak, swollen, and irritated (inflamed), and
it can hurt when you stand or walk.

Conditions or activities that
may lead to plantar fasciitis include:

Things that affect how the feet work
(biomechanical factors). These include abnormal inward twisting or rolling of
the foot (pronation), high arches, flat feet, tight calf
muscles, or tight tendons at the back of the heel (Achilles tendons).

Repetitive
activities, such as jobs that require prolonged walking or standing on hard or
irregular surfaces or sports such as running.

Things that put
extra stress on the feet, such as being overweight or wearing shoes that are
poorly cushioned, don't fit well, or are worn out.

The natural
process of aging. Plantar fasciitis is most common in middle-aged
adults.

In rare cases, a single injury to the foot.

Symptoms

The classic symptom of
plantar fasciitis is heel pain when you take your
first steps after getting out of bed or after sitting for a long period of
time. You may also have:

Stiffness and pain in the morning or after
resting that gets better after a few steps but gets worse as the day
progresses.

Pain that gets worse when you climb stairs or stand on
your toes.

Pain after you stand for long periods.

Pain
at the beginning of exercise that gets better or goes away as exercise
continues but returns when exercise is completed.

What Happens

Plantar fasciitis usually develops gradually. You may have heel pain only when
you take your first steps after getting out of bed or after sitting for a long
period of time. If you do not rest your feet, the pain will get worse. Other
things, such as the repetitive stress of walking, standing, running, or
jumping, will add to the injury,
inflammation, and pain. The injured ligament may never
heal completely if you are not able to stop the activity or change the
condition that caused it.

As plantar fasciitis progresses:

The heel pain gradually gets
worse.

You may change the way you walk to relieve the pain. This
eventually may lead to more discomfort and pain and other problems with your
foot, leg, hip, or back. Daily activities or sports may become even more
limited.

You eventually may have pain with any weight-bearing
activity. Running and jumping may no longer be possible.

A
heel spur may form as a result of continued stress as
the plantar fascia pulls on the heel bone. (By itself, a heel spur does not
cause plantar fasciitis and does not usually cause problems. And you can have
plantar fasciitis and not have a heel spur.)

If the condition is not treated, plantar fasciitis can
cause constant heel pain when you stand or walk.

What Increases Your Risk

You have a greater chance of
developing
plantar fasciitis if you:

Are middle-aged or older.

Walk with
an inward twist or roll of the foot (pronation) or have high arches or flat
feet.

Who to see

If nonsurgical treatments fail to relieve your pain, your
doctor may refer you to a specialist such as an orthopedist or podiatrist. If
you are an athlete, your doctor may refer you to a sports medicine specialist
to look for problems with how your feet strike the ground, how your feet are
shaped, or your training routine.

The following health
professionals can do surgery:

Podiatric surgeon

Orthopedic
surgeon, especially one who specializes in foot and ankle
conditions

Exams and Tests

To diagnose
plantar fasciitis, your doctor will ask questions
about your symptoms and your past health. He or she will also do a
physical exam of your feet that includes watching you
stand and walk.

X-rays aren't helpful in diagnosing plantar
fasciitis, because they do not show ligaments clearly. But your doctor might
take X-rays if he or she suspects a
stress fracture, bone cyst, or other foot or ankle
bone problems. X-rays may show whether a
heel spur is present, but a bone spur does not
necessarily mean that a person has plantar fasciitis.

If the
diagnosis is not clear, you may have other tests. Tests that are done in rare
cases include
MRI, blood tests, bone scans, and vascular testing,
which can evaluate blood flow in the foot and lower leg. If your doctor
suspects nerve entrapment, you may have neurological testing.

Treatment Overview

The goals of treatment for
plantar fasciitis are to:

Relieve
inflammation and pain in the heel.

Allow
small tears in the plantar fascia ligament to heal.

Improve
strength and flexibility and correct foot problems such as
excessive pronation so that you don't stress the plantar fascia
ligament.

Allow you to go back to your normal activities.

Most people recover completely within a year. Out
of 100 people with plantar fasciitis, about 95 are able to relieve their heel
pain with nonsurgical treatments. Only about 5 out of 100 need surgery.footnote 1

Treatment
that you start when you first notice symptoms is more successful and takes less
time than treatment that is delayed.

Initial treatment

There are many methods you can
try to relieve the heel pain of
plantar fasciitis. Even though their effectiveness has not
been proved in scientific studies, these methods, used alone or in combination,
work for most people.footnote 2

To reduce inflammation
and relieve pain, put
ice on your heel. You can also try a
nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen (Advil or
Motrin, for example) or naproxen (Aleve, for example). NSAIDs come in pills and in a cream that you rub over the sore area.

Wear shoes with good shock absorption and the right arch support
for your foot. Athletic shoes or shoes with a well-cushioned sole are usually
good choices.

Try heel cups or shoe inserts (orthotics) to help
cushion your heel. You can buy these at many athletic shoe stores and
drugstores. Use them in both shoes, even if only one foot
hurts.

Put on your shoes as soon as you get out of bed.
Going barefoot or wearing slippers may make your pain worse.

Do simple exercises such as
toe stretches, calf stretches, and
towel stretches several times a day, especially when you first get up in the
morning. These can help your ligament become more flexible and strengthen the
muscles that support your arch. (For towel stretches, you pull on both ends of a rolled towel that you place under the ball of your foot.)

Avoid using only heat on your foot, such as from a
heating pad or a heat pack for at least the first 2 or 3 days. Heat tends to make symptoms worse for some people. If you use
contrast baths, which alternate hot and cold water,
make sure you end with a soak in cold water. If you try a heating pad, use a low setting.

If your weight is
putting extra stress on your feet, your doctor may encourage you to try a
weight-loss program.

Ongoing treatment

If nonsurgical methods such as
rest, ice, and stretching exercises help relieve your
plantar fasciitis symptoms, continue using them. If
you have not improved after 6 weeks, your doctor may recommend that you
continue those methods but add other nonsurgical treatments, such as:

Custom-made
shoe inserts (orthotics). Custom-made orthotics
require a prescription. If your foot has an unusual shape or if you have a certain
problem that the device will help, then a custom-made insert may fit better and
control pain better than a nonprescription one.

Night splints. A night splint holds the foot with the
toes pointed up and with the foot and ankle at a 90-degree angle. This position
applies a constant, gentle stretch to the plantar fascia.

A
walking cast on the lower leg. Casting is somewhat
more expensive and inconvenient than other nonsurgical treatments. And after
the cast is removed, you will need some rehabilitation to restore strength and
range of motion. But a cast forces you to rest your foot.

Formal
physical therapy instruction can help make sure you properly stretch your Achilles tendon and plantar fascia ligament. Doctors usually
consider surgery only for severe cases that do not improve.

Treatment if the condition gets worse

Your doctor may suggest
corticosteroid shots if you have tried nonsurgical
treatment for several weeks without success.footnote 1 Shots
can relieve pain, but the relief is often short-term. Also, the shots themselves can be
painful, and repeated shots can damage the heel pad and the plantar
fascia.

Out of 100
people with plantar fasciitis, about 95 are able to relieve their heel pain
with nonsurgical treatments. Only about 5 out of 100 need surgery.footnote 1 If you are one of the few people whose symptoms don't improve
in 6 to 12 months with other treatments, your doctor may recommend
plantar fascia release surgery. Plantar fascia release
involves cutting part of the plantar fascia ligament in order to release the
tension and relieve the inflammation of the ligament.

What to think about

If you are trying to lose
weight and you develop plantar fasciitis when you begin exercising, especially
jogging, talk with your doctor about other types of activity that will support
your weight-loss efforts without making your heel pain worse. An activity like
swimming that doesn't put stress on your feet may be a good choice.

If your plantar fasciitis is related to sports or your job, you may have
trouble stopping or reducing your activity to allow your feet to heal. But
resting your feet is very important to avoid long-lasting heel pain. Your
doctor or a
sports medicine specialist may be able to suggest a
plan for alternating your regular activities with ones that do not make your
pain worse.

If you exercise frequently, ask your doctor
whether physical therapy or referral to a sports medicine
specialist,
podiatrist, or
orthopedist is appropriate.

Some questions you may want to ask about exercise include:

Should I cut back on my exercise? How many days
per week, how long, and what exercise should I do instead?

Should I
ice my foot after I exercise? If so, for how long each time, and how long
should I continue the icing?

Should I use nonsteroidal
anti-inflammatory drugs (NSAIDs) either before or after I
exercise?

Are there exercises I can do to make my foot
and ankle more flexible? What are they, and how often and how long should I do
them?

Prevention

The following steps will help prevent
plantar fasciitis or help keep the condition from
getting worse if you already have it:

Take care of your feet. Wear shoes with good
arch support and heel cushioning. If your work requires you to stand on hard
surfaces, stand on a thick rubber mat to reduce stress on your
feet.

Do exercises to stretch the
Achilles tendon at the back of the heel. This is
especially important before sports, but it is helpful for nonathletes as well.
Ask your doctor about recommendations for a stretching
routine.

If you run, alternate
running with other sports that will not cause heel pain.

Put on supportive shoes as soon as you get out of bed. Going
barefoot or wearing slippers puts stress on your feet.

If you feel that work activities caused your heel pain, ask
your human resources department for information about different ways of doing
your job that will not make your heel pain worse. If you are involved in
sports, you may want to consult a sports training specialist for training and
conditioning programs to prevent plantar fasciitis from recurring.

Home Treatment

The first steps your doctor will
recommend to treat
plantar fasciitis are ones you can take yourself.
Different people find that one method or a combination of methods works best
for them.

Try the following methods:

Rest your feet. Stop or reduce any activities
that may be causing your heel pain.

Wear supportive footwear. Wear
shoes that have good arch support and heel cushioning. Or buy
shoe inserts (orthotics). Shoe inserts may be made of
plastic, rubber, or felt. Orthotics can reduce stress and pulling on the
plantar fascia ligament.

Use ice on your heel. Ice can help
reduce
inflammation.
Contrast baths, which alternate hot and cold water,
can also be helpful. Heat alone may make symptoms worse for some people, so always end a
contrast bath with a soak in cold water. If ice isn't helping after 2 or 3 days, try heat, such as a heating pad set on low.

Take ibuprofen (such as
Advil or Motrin), naproxen (such as Aleve), or another
nonsteroidal anti-inflammatory drug (NSAID) to reduce pain and
inflammation. NSAIDs come in pills and in a cream that you rub over the sore area. Be safe with medicines. Read and follow all instructions on the label.

Wear
night splints. Night splints gently stretch the
plantar fascia ligament and Achilles tendon and keep them from getting tight
during the night.

Do stretching and strengthening exercises. Exercises for
stretching the Achilles tendon and plantar fascia will increase their
flexibility. Exercises to strengthen the muscles of the foot and ankle will
help support the arch.

Often athletes develop foot problems because they train in
shoes that are worn out or don't fit properly. Replace your shoes every few months, because the padding wears out. Also, replace shoes if the tread or heels are worn down. While replacing shoes is expensive, it is less expensive—and less painful—than a long-lasting heel problem. Other
sensible training techniques, such as avoiding uneven
or hard surfaces, can help prevent plantar fasciitis from occurring or
returning.

If your weight is putting extra stress on your feet,
your doctor may encourage you to try a weight-loss program.

To be
successful at treating plantar fasciitis, you will need to:

Be patient and consistent. The majority of
cases of plantar fasciitis go away in time if you regularly stretch, wear good
shoes, and rest your feet so they can heal.

Start treatment right
away. Don't just ignore the pain and hope it will go away. The longer you wait
to begin treatment, the longer it will take for your feet to stop
hurting.

The healing process takes time—from a few months to a
year. But you should begin to have less pain within weeks of starting treatment.
If you have not improved after trying these methods for 6 weeks, your doctor
will suggest other treatments.

Medications

Your doctor may recommend medicine to
relieve the pain and
inflammation caused by
plantar fasciitis. Drug treatment does not cure
plantar fasciitis. But by reducing pain, medicine may make it easier for you to
follow other treatment steps, such as stretching. You should not use
medicine as a way to continue the activities that are causing heel
pain.

Medicine options include:

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as
ibuprofen (Advil or Motrin, for example) or naproxen (Aleve, for example). You can buy these medicines without a prescription. NSAIDs are often
used if you have only had symptoms of plantar fasciitis for a few days or
weeks. They are less likely to work if you have had symptoms for more than 6 to
8 weeks. NSAIDs come in pills and in a cream that you rub over the sore area.

Corticosteroid shots. Your doctor may recommend shots
if you have tried other treatments for several weeks without success.footnote 1 Doctors may recommend shots sooner for some people.

Injections of botulinum toxin are being studied for use in plantar fasciitis.

Surgery

Surgery is usually not needed for
plantar fasciitis. About 95 out of 100 people who have
plantar fasciitis are able to relieve heel pain without surgery. Your doctor
may consider surgery if nonsurgical treatment has not helped and heel pain is
restricting your daily activities. Some doctors feel that you should try
nonsurgical treatment for at least 6 months before you consider
surgery.footnote 1

Other procedures, such as removing a
heel spur or stretching or loosening specific foot
nerves. These surgeries are usually done in combination with plantar fascia release when there is lasting heel pain and another
heel problem.

Experts in the past thought that heel spurs caused plantar
fasciitis. Now experts generally believe that heel spurs are the result, not
the cause, of plantar fasciitis. Many people with large heel spurs never have
heel pain or plantar fasciitis. So surgery to remove heel spurs is rarely
done.

Other Treatment

Physical therapy may
be helpful for some people who have
plantar fasciitis. It can be especially useful for
people who have problems with foot mechanics (biomechanical problems), such as
tight
Achilles tendons.

A technique called
extracorporeal shock wave therapy (ESWT) uses pulsed sound waves to treat
plantar fasciitis. Research is still being done, but some studies show that ESWT can help reduce symptoms in plantar fasciitis that has not responded to other treatment.footnote 3, footnote 4 New shock wave
treatments are being studied. Most types of shock wave therapy, sometimes
called "focused" ESWT, require anesthetic. Another type, called radial ESWT,
can be done without anesthetic, because the shock wave is more spread
out.

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